Understanding new international guidelines to tackle CV Risk:
A practical model
John Deanfield, MDUCL, London
United Kingdoms
Ho Chi Minh City, VietnamAugust 7, 2014
JBS 2 Risk Guidelines (2005)Based on Short term (10yr) Absolute Risk
Treat ‘risk’ not risk factors
Focus on highest 10 year risk
But things have changed!
Recent CV Guidelines
USA: November 2013 UK: February 2014
ACC/AHA Guidelines
Treat risk not Risk
factors
No lipid targets
Only consider RCT
evidence
Target 4 groups
- Established CVD
- Diabetes
- FH
-10 yr CV risk > 7.5%November 2013
Elderly black man
79yr of age
Total cholesterol 150 mg/dl
HDL cholesterol 40 mg/dl
Systolic blood pressure 120 mmHg
Not taking antihypertensive medication
Not diabetic
Nonsmoker
Calculated 10-yr risk of CHD or stroke 13.7%
Comment: Patient qualifies because he has
a 10-yr risk of >7.5% but is >75 yr of age.
Moderate-Intensity Statin Therapy
Recommended
Kearney NEJM 2014; 370: 275-278
New Cholesterol Guidelines to a Population-Based Sample
Pencina NEJM 2014; 370: 1422-31
56 million people
European Heart Journal 2012; 33: 1635-1701
ESC CV Prevention Guidelines 2012
Disenfranchises the
young, especially women!
White woman with hyperlipidemia and hypertension
46yr of age
Total cholesterol 230 mg/dl
HDL cholesterol 55 mg/dl
Systolic blood pressure 150 mmHg
Taking antihypertensive medication
Not diabetic
Nonsmoker
Calculated 10-yr risk of CHD or stroke 2.0% Comment:
Total cholesterol is high and
blood pressure is not controlled, but
patient has no other risk factors.
Statin Therapy Not Recommended
Kearney NEJM 2014; 370: 275-278
Non-smoking men <45yrs
All women <65yrs
<10% 10yr CHD Risk
56% of US adults (87,000,000)
have low (<10%) 10yr and high
lifetime (≥39%) risk
Marma Circ Cardiothoracic Qual Outcomes 2010;3:8-14
Marma Circ 2009;120:384-390
Short Term v. Lifetime Risk in USA
25 yrs 40yrs 58yrs
TC 310 mg/dl 310 mg/dl 310 mg/dl
HDL 50 mg/dl 50 mg/dl 50 mg/dl
TG 400 mg/dl 400 mg/dl 400 mg/dl
LDL 180 mg/dl 180 mg/dl 180 mg/dl
FH of CVD – – –
BMI 25 kg/m2 25 kg/m2 25 kg/m2
10 yr risk – 3.1% 7.5%
Young Man comes to your
Clinic at 25 years
“Waiting for dyslipidemic
patients to reach middle age
before starting therapy is a
failure of prevention”
Hazen 2014
Joint British Societies (JBS)3:
March 26th 2014
Early intervention pays long term dividends
Investing in Your Arteries!
JBS3 : What’s different?
“Investing in Your Arteries”
Personalised, lifetime approach to CVD
prevention
New CVD risk calculator with understandable
risk metrics linked to interventions .Demonstrate
the potential for benefit on a person’s risk over their
lifetime.
Provides CV risk management guidance for the
whole range of people.
Empower individuals to take control of their
CVD health by promoting lifestyle changes,
not just drugs
Heart March 2014 and www.jbs3risk.com
Established CVD or
Familial Hypercholesterolaemia
Diabetes age >40 years
Chronic Kidney Disease
Lifestyle and drug therapy
as recommended in JBS3
10 year CVD risk scoreABOVE current NICE threshold*:
Lifestyle + Drug therapy
BELOW current NICE threshold*
Examine JBS3 ‘lifetime metrics’
Heart age
Projected CVD risk
To inform discussion on risk
modification by:
Lifestyle changes
Drug therapy when indicated
Ongoing research on
implementation and impact of
JBS3 recommendations and
risk calculator
*Current NICE Guidance www.nice.org.uk
NO YES
Use JBS3 risk calculator
JBS3 CVD Risk Approach
www.jbs3risk.com
JBS3 CVD Risk Calculator35 year old female: adverse risk factors
Heart March 2014 and www.jbs3risk.com
Heart March 2014 and www.jbs3risk.com
JBS3 : Start of a new Process
Changes interactions
in primary care
Personalised approach
Empowers lifestyle
Not just a statin
conversation!
Implementation and Evaluation challenges!
JBS3: Patient Pull
Patient friendly app Send programme with
individual data
Health Checks JBS3
• Understanding• Behaviour• Risk factors• CV events
Next Steps: Formal
Evaluation in Primary care
Lifetime CVD Risk Management
JBS3 platform applicable to other NCDs
such as dementia which share risk factors
BP (1990-92) Gottesman JAMA Neurol 2014; 1646: E1-10
CV disease is preventable
“Life-long Rx likely to be cost-effective and
often cost saving”Circulation 2011;124:967-990
Joint British Societies (JBS)3:
March 26th 2014
Strategy to communicate CV risk to rest of us as well as opportunities for lifetime
benefit
Management of High short term Risk
Recommended
